Value of a multidisciplinary geriatric oncology committee on patient care in a community-based, academic cancer center

INTRODUCTION

The heterogeneity in health and functional ability among older patients makes the management of cancer a unique challenge. The Geriatric Oncology Program at the University of Maryland Baltimore Washington Medical Center (BWMC) was created to optimize cancer management for older patients. This study aimed to assess the benefits of the implementation of such a program at a community-based academic cancer center.

MATERIALS AND METHODS

We analyzed patients aged ≥80 years presenting to the Geriatric Oncology Program between 2017 and 2022. A multidisciplinary team of specialists collectively reviewed each patient using geriatric-specific domains and stratified each patient into one of three management groups- Group 1: those deemed fit to receive standard oncologic care (SOC); Group 2: those recommended to receive optimization services prior to reassessment for SOC; and Group 3: those deemed to be best suited for supportive care and/or hospice care.

RESULTS

The study cohort consisted of 233 patients, of which 76 (32.6%) received SOC, 43 (18.5%) were optimized, and 114 (49.0%) received supportive care or hospice referral. Among the optimized patients, 69.8% were deemed fit for SOC upon re-evaluation following their respective optimization services. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) score was implemented in 2019 (n = 90). Patients receiving supportive/hospice care only had an average score of 5.8, while the averages for those in the optimization and SOC groups were 4.6 and 4.1, respectively (p ≤0.001). Patients receiving SOC had the longest average survival of 2.71 years compared to the optimization (2.30 years) and supportive care groups (0.93 years) (p ≤0.001). For all patients that underwent surgical interventions post-operatively, 23 patients (85%) were discharged home and four (15%) were discharged to a rehabilitation facility.

DISCUSSION

The present study demonstrates the profound impact that the complexities in health status and frailty among older individuals can have during cancer management. The Geriatric Oncology Program at BWMC maximized treatment outcomes for older adults through the provision of SOC therapies and optimization services, while also minimizing unnecessary interventions on an individual patient-centric level.

Analysis of 10 years of open, laparoscopic, and robotic rectal surgeries in the community setting

Background

Colorectal cancer is the fourth most common cancer in the US. Many of these patients will require operations. Although there is significant data in the literature that supports minimally invasive colorectal operations in the academic setting, few studies have examined their performance in community hospitals.

Methods

Data was collected from a high-volume, university-affiliated, community center. Our Cancer Registry Database was queried to include any patients that had rectal surgery at our institution from 2010 to 2020. One hundred-twenty-two patients were identified and reviewed retrospectively. Main outcome measures include estimated blood loss (EBL), blood transfusion, time to first bowel movement, oncologic resection, length of stay (LOS), survival, and cost analysis.

Results

Both robotic and laparoscopic operations resulted in lower average EBL, less blood transfusions, and less time to first bowel movement (p = 0.003, 0.006, 0.003, respectively). There was no significant difference in ability to achieve R0 resection, adequate lymph node retrieval, and adequate total mesorectal excision (TME, p = 0.856, 0.489, 0.500, respectively). LOS was significantly shorter for minimally invasive operations, 4.35 vs 8.48 days, and average survival was longest for laparoscopic operations at 7.19 years as compared to 5.55 years for open operations (p < 0.001, 0.026, respectively). Cost was lowest for robotic operations (0.003).

Conclusions

Minimally invasive rectal operations, especially robotic, lead to better short- and long-term outcomes, equivalent oncologic resection, and are more cost-effective as compared to open operations even in the community setting, supporting continued performance and growth of robotic colorectal operations in the community setting.

Key message

Although there is significant data in the literature that supports minimally invasive colorectal operations in the academic setting, few studies have examined their performance in community hospitals as this study does. This study found that minimally invasive rectal operations, especially robotic, lead to better short- and long-term outcomes, equivalent oncologic resection, and are more cost-effective as compared to open operations even in the community setting, supporting continued performance and growth of robotic colorectal operations in the community setting.

Synergetic role of integrating the departments of cancer registry and clinical research at an academic comprehensive cancer center

Integration of the cancer registry and clinical research departments can have a significant impact on the accreditation process of a Commission on Cancer (CoC) Program. Here in we demonstrate that the integration of both departments will benefit as there is increased knowledge, manpower and crossover in job responsibilities in our CoC-accredited Academic Comprehensive Cancer Center. In our model this integration has led to a more successful cooperative interaction among departments, which has in turn created an enhanced combined effect on overall output and productivity. More manpower for the cancer registry has led to increased caseloads, decreased time from date of first contact to abstraction, quality of data submissions, and timely follow-up of all patients from our reference date for accurate survival analysis along with completeness of data. In 2016, our Annual Facility report showed an additional 163 cases over prediction by the state of Maryland Cancer Registry and a 39% increase in case completeness. As proof of the synergetic effectiveness of our model within one year of its implementation, the cancer center was able to apply for, and was awarded membership from Alliance for Clinical Trials in Oncology, Central IRB, and in turn led to increased clinical trial accrual from 2.8% in 2014 compared to 13.2% currently. Our cancer registry in year one submitted over 150 more cases than predicted, improved quality outcome measures displayed by our Cancer Program Practice Profile reports and had more timely and complete data submissions to national and state registries. This synergetic integration has led to a better understanding, utilization and analysis of data by an integrated team with Clinical Research expertise.

Monitoring medication adherence in multiple sclerosis using a novel web-based tool: A pilot study

Monitoring medication adherence in multiple sclerosis (MS) can be time consuming and expensive; however, non-adherence is common and is very costly in terms of lost therapeutic benefit and unused medications. To address this problem, we employed a web-based system to monitor and potentially modify medication adherence. Participants ( n = 30) were randomized either to routine care or to the MS Home Automated Telehealth (MS HAT) system. Weekly interferon beta-1a intramuscular (INFbeta-1a IM) injections and daily vitamin D adherence were tracked over a six-month period using multiple modalities: self-reported adherence, calendar diaries, pharmacy refill rates, blood serum levels, and MS HAT alerts. Weekly INFbeta-1a IM adherence was highly correlated across measures; however, vitamin D adherence was not as consistent. Healthcare providers were able to efficiently monitor adherence in a patient-centered way by using the MS HAT system to monitor adherence rather than employing chart reviews and phone calls. In addition, patients with more preserved cognitive function appeared to benefit more from use of the MS HAT system than those with cognitive impairment. While further research is needed to understand the differential effects of MS HAT on specific medications and for different individuals, it is a promising tool for monitoring medication adherence in patients with MS.

Feasibility of post-acute hip fracture telerehabilitation in older adults

Recent studies demonstrated potential of home-based telerehabilitation in older adults and individuals with mobility impairment. However limited evidence exists on feasibility of home-based telerehabilitation in older adults after hip fracture. The aims of this study were: (1) to assess impact of home-based telerehabilitation of community dwelling older adults in post-acute phase of recovery after hip fracture on mobility, psycho-behavioral factors, quality of life, and satisfaction with care; (2) to estimate acceptance of the telerehabilitation system and adherence to the exercise program. We found statistically significant improvements in exercise self-efficacy, mobility, quality of life, and patient satisfaction after 30-day hip fracture telerehabilitation. Home telerehabilitation may be a viable model for post-acute hip fracture recovery and it is warranted for further evaluation in clinical trials.

Computerized Insulin Order Sets Can Lead to Unanticipated Consequences

Computerized order sets for medication management were recently shown to be associated with increased patient safety risks in primary care setting. This study was aimed at demonstrating similar phenomenon in a hospital setting. After introduction of computerized order set targeting hypoglycemia, the frequency of hypoglycemia significantly decreased from 1/1/07 to 12/31/08. However, the frequency of hyperglycemia also increased at the same time from 1/1/07 to 12/31/07. Only after subsequent introduction of a hospital-wide standardized insulin order set including hyperglycemia policies, the frequency of hyperglycemic episodes declined. Hypo/hyperglycemia is associated with adverse clinical outcomes in the inpatient setting. Retroactive analysis showed that if hypoglycemic and hyperglycemic policies were introduced simultaneously, unexpected increase in frequency of hyperglycemic episodes could have been avoided. These data are informative in identifying unanticipated consequences of an insulin management order sets focused entirely on hypoglycemia. A balanced approach in implementing insulin management EMR order sets that concurrently addresses both hypoglycemia and hyperglycemia policies is warranted.

Mobile App to Reduce Inactivity in Sedentary Overweight Women

Recent studies demonstrated that the duration of inactivity (sedentary state) is independently associated with increased risk of cardiovascular disease. Our goal was to develop the technology that can measure the amount of inactivity in real time, remind a person that a preprogrammed period of inactivity has occurred and encourage a period of activity, and provide web-based feedback with tailored information to the participant and investigators. Once it was developed, we carried out a pilot study in a group of sedentary overweight women. The objective of the study was to assess potential of the mobile app to reduce inactivity in our target population. A randomized crossover design was employed with study subjects randomly assigned to a 4-week each "message-on" and "message-off" periods. Out of 30 enrolled subjects, 27 completed the study. The average age of particpants was 52±12; BMI: 37±6; 47% were white and 47% were African American. Overall, inactivity was significantly lower (p&lt;0.02) during "message-on" periods (24.6%) as compared to the "message-off" periods (30.4%). We conluded that mobile app monitoring inactivity and providing a real-time notification when inactivity period exceeds healthy limits was able to significantly reduce inactivity periods in overweight sedentary women.

Introducing Home Blood Pressure Telemonitoring for Children with Hypertension

The goal of this study was to introduce home blood pressure (BP) telemonitoring in children with hypertension and to assess the feasibility of this approach. Acceptance of the system was assessed by attitudinal survey and semi-structured qualitative interview. Qualitative interview results showed consistently positive comments for content, interface and process components. BP measurements obtained by self-testing were as reliable as Dinamap measurements. The home telemonitoring system was positively accepted, easy to use and found to be helpful by participants. Home-based BP telemonitoring has significant potential to improve patient-centered delivery in children with hypertension.

Exploring three perspectives on feasibility of a patient portal for older adults

INTRODUCTION

It is not clear whether older adults with chronic disease and their caregivers are likely to use patient portals.

METHODS

Older adults with a diagnosis of chronic obstructive pulmonary disease or congestive heart failure were evaluated as well as their caregivers. We explored whether these patients and/or their caregivers were able to use common portal elements. The perspective of informatics experts was ascertained using cognitive walkthrough methodology.

RESULTS

Fourteen patients and nineteen caregivers were evaluated. Patients required more time on all tasks than caregivers. Patient comments included a request for written instructions for using the system and a guide for interpreting lab results. Caregiver suggestions included improving color contrast and presentation of the current medication list. In the cognitive walkthrough, numerous problems were identified.

CONCLUSIONS

Older adults with chronic illness and caregivers were interested in using a patient portal however multiple barriers were identified.

A critical review of consumer health devices for stress self-management

A number of consumer health devices have been advertised as effective means to manage individual stress. However, objective evidence of their efficacy is not readily available. We present a critical analysis of evidence related to efficacy of stress management devices based on comprehensive literature review and information provided by the vendors. The analysis was conducted along four dimensions: metrics, theoretical frameworks, evaluation, and FDA clearance. The review resulted in identification of critical issues including limited information on operational characteristics, controversial theoretical underpinnings, and lack of systematic evaluation. Efficacy of these consumer devices has yet to be established.

Avatar-based interactive ileostomy education in hospitalized patients

Computer-assisted education can be an effective means for patient engagement and empowerment however the feasibility of postoperative computer-assisted ileostomy education has not been studied systematically. The purpose of this study was to assess feasibility and patient acceptance of tablet-based interactive ileostomy education in patients with new stomas, and to evaluate the impact of this education modality on knowledge and self-efficacy. An interactive multimedia education for ileostomy management guided by adult learning theories was tested in 15 hospitalized patients with new ileostomies. After using the avatar-based education, the ileostomy knowledge score improved from 27.8±3.4 to 31.3±1.5 (p<0.002) and stoma care self-efficacy improved from 78.4±22.7 to 92.7±14.1 (p<0.05). Attitudinal surveys and qualitative interviews demonstrated high level of acceptance and provided valuable feedback for future improvements. We concluded that avatar-based interactive instruction can potentially be an effective means to deliver health education to hospitalized patients.

Defining patient-centered characteristics of a telerehabilitation system for patients with COPD

Studies have shown that pulmonary rehabilitation in patients with chronic obstructive pulmonary disease (COPD) can help to restore or enhance residual functional capacity and improve quality of life. Home-based telemedicine systems can promote comprehensive pulmonary rehabilitation in COPD patients. Successful acceptance of such systems depends on how well they reflect needs, values and preferences of older adults with COPD. However, patient-centered characteristics of pulmonary telerehabilitation systems were not systematically defined particularly in older adults. The goal of this pilot study was to assess older COPD patient acceptance of pulmonarytelerehabilitation and to develop patient-centered characteristics of computer technology to support pulmonary rehabilitation at homes of older adults with COPD based on their values, needs, and preferences. A prototype pulmonarytelerehabilitaton system was developed and demonstrated to patients. The system feasibility and acceptance was assessed by identifying patient ability to operate the system independently and by collecting open-ended feedback via semi-structured qualitative interview and attitudinal surveys. Older adults found this technology easy to operate and potentially useful personal rehabilitation. Patient-centered specifications of a comprehensive pulmonary telerehabilitation system in older adults with COPD were identified.

Is Internet search better than structured instruction for web-based health education?

Internet provides access to vast amounts of comprehensive information regarding any health-related subject. Patients increasingly use this information for health education using a search engine to identify education materials. An alternative approach of health education via Internet is based on utilizing a verified web site which provides structured interactive education guided by adult learning theories. Comparison of these two approaches in older patients was not performed systematically. The aim of this study was to compare the efficacy of a web-based computer-assisted education (CO-ED) system versus searching the Internet for learning about hypertension. Sixty hypertensive older adults (age 45+) were randomized into control or intervention groups. The control patients spent 30 to 40 minutes searching the Internet using a search engine for information about hypertension. The intervention patients spent 30 to 40 minutes using the CO-ED system, which provided computer-assisted instruction about major hypertension topics. Analysis of pre- and post- knowledge scores indicated a significant improvement among CO-ED users (14.6%) as opposed to Internet users (2%). Additionally, patients using the CO-ED program rated their learning experience more positively than those using the Internet.